Eating Disorders Manifestations in Young Women - Case Study Example

Is this a resubmission? Yes  No x Eating disorders’ manifestations in young women present psychosocial challenges to the patient and unusual choices for counselors and clinical care givers. The case at hand involves Tania, a 23-year-old female law student living in an urban neighborhood with her parents who could be described as busy doctors and a 21-year old brother, also a law student, she describes as outgoing and popular. Tania has had a dieting history for the last 9 years and though she has been cooking for the family for the last one year, she, of late, no longer eats with her family. She has, also, imposed on herself, food restrictions and an excessive exercising regime over the last 6 months. The patient has lost 26kg in the past one year and gained 4cm height within the same period. Her weight and height are currently 40kg and 1.64m respectively. She, however, still believes she is overweight and needs to lose more weight. Tania denies binging and laxative abuse. She views her parents’ concerns over her state seen as unnecessary intrusion and this subject leads to family disagreements. The family doctor has been treating her for gastrointestinal disturbances over the past 2 months. She also complains of feeling faint. She has been advised to eat more fiber, take an ECG examination and consult a cardiologist. Research into eating disorders among Australian university students has addressed several issues on this mental condition. Sjostedt, Schumaker and Nathawat (1998) studied the incidence of eating disorders in Australian and Indian university women and men. Stephens, Schumaker and Sibiya (1999) investigated the dieting disorders and behavior among students in Swazi and Australian universities. Another important study on university students’ eating disorders, though not targeting Australian students, focused on how the students who manifested eating disorders functioned socially and emotionally (Grabarek & Cooper, 2008). These and other related studies provide important insights into clinical assessment and management of cases of eating disorders such as Tania’s. The implications of attitude and stigmatization on treatment and recovery of eating disorder patients are also addressed. Eating disorders have been defined as complex psychiatric syndromes characterized by cognitive distortions about food and body weight which result into abnormal eating patterns that can lead to potentially life-threatening nutritional and medical conditions. Approaching Tania’s eating disorder as a mental health issue would yield a better prognosis and intervention outcome. This is because documented evidence shows that a reasonable percentage of young people (particularly urbanite women) who perceive themselves as overweight do resort to obsessive weight loss measures – dieting being the most popular. Though dieting in itself cannot be described as a disorder, it is, in some cases, a manifestation of a mental illness. Tania is reported to have been dieting since she was 14 years but in the last 12 months, she has been manifesting symptoms of an eating disorder. In theoretical terms, Tania’s is case of planned behavior syndrome. Ajzen’s (1991) theory of planned behavior has been used to explain and predict eating disorders (Pickett, et al., 2012). This theory posits that one’s behavior is predictable, mostly on the basis of their intentions while attitude, perceived behavioral control, and subjective norms also play significant roles. Pickett et al. (2012) observe that severe eating habits which characterize eating disorders leads to any of three main types of the disorder: anorexia nervosa (AN), bulimia nervosa (BN), and eating disorders not otherwise specified (EDNOS). The criteria for assessing Tania’s condition should be based on the symptoms she presents and her history. The patient’s history suggests two possibilities: anorexia nervosa or bulimia nervosa. To ascertain her condition, four screening tools can be used. They include the Eating Disorder Inventory – EDI (Joiner & Heatherton, 1998); the SCOFF Questionnaire (Morgan, Reid & Lacey, 1999); the Eating Attitudes Test – EAT (Garner et al., 1982); and the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition – DSM-IV (American Psychiatry Association, 2000). While the first three are tools for generally assessing eating disorders, DSM-IV is a clinical tool for screening and determining the magnitude of anorexia nervosa. The Eating Disorder Inventory (EDI) is a self-report instrument with 64 items for measuring leading eating habits and attitudes. Through this tool, the clinician gets to establish the patient’s drive for thinness, body dissatisfaction, bulimia, perfectionism, maturity fears and interpersonal distrust among other indicators. Tania presents some of these symptoms, notably her belief that she is still fat and that she should continue losing weight even after losing 20kg in 12 months. This kind of body dissatisfaction is telling enough since Tania is actually underweight with a body mass index (BMI) of 17.269kg.m-2. Tania also manifests interpersonal trust issues when she looks at her parents’ concern about her health as unwarranted interference. The SCOFF Questionnaire is another tool that could be used to diagnose Tania’s condition. The instrument comprises five questions addressing different manifestations namely making yourself sick when you feel uncomfortably full; worrying about losing control over eating; having lost more than one stone (6.35Kgs) within the last 3 months; believing to be fat when others say you are very thin; and feeling that food dominates your life. Since research has proved that orally administered questionnaires avails more reliable results than written interviews, the oral interview will be preferred in Tania’s case. The patient’s responses to these questions will form a good basis for Tania’s prognosis. The fact that Tania has consulted the family doctor over gastrointestinal discomforts strongly suggests that she makes herself sick (in this case of bloat and constipation) on account of feeling disturbingly full. It is obviously clear that Tania having lost, in a year, a total of 26kg which translates to about 6.5kgs per a quarter of a year will also say “yes” to the third question. This makes her susceptible to an eating disorder according to the SCOFF Questionnaire. It will be particularly essential to establish if Tania worries about losing control over eating and as this may explain her being advised to take an ECG and to consult a cardiologist. Worries and anxiety could be responsible for heart palpitations which are also a symptom of an eating disorder (anorexia nervosa). Tania is likely to say “yes” to more than two of the questions indicating that hers is a case of either anorexia nervosa or bulimia nervosa. Another screening tool, the Eating Attitudes Test will be instrumental in diagnosing this patient’s attitudinal and behavioral characteristics such as avoidance of foods considered to be fattening, desire to get thinner, external pressure to gain weight, binge eating and food intake control. Lee, Lee, Leung and Yu (1997) attest to the efficacy of this test in diagnosing anorexia nervosa (which Tania seems to suffer from). Having established from the above tools that Tania’s is a case of anorexia nervosa, a clinical diagnostic tool – the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) for anorexia is used to measure the magnitude of the patient’s illness. This scale has the following four measurement criteria: refusing to maintain the body weight at or above the minimum for the age and height, Intense phobia for becoming fat even if one is underweight., Body weight or shape disturbance, undue effect of body weight/shape on self-evaluation, and denial of the gravity of the low current body weight, and Amenorrhea in post-menarcheal women. The case at hand manifests the first three symptoms. The third is very pronounced. The patient describes her younger brother as popular and outgoing – she possibly thinks that she lacks these qualities due to her body weight/shape. This is an example of undue influence of perceived body weight on self-evaluation. The patient also denies the seriousness of her state of health when the parents raise it as an issue. Discussing this issue ends in disharmony and arguments. It is important to note that there are two types of anorexia: the restricting type and the binge-eating or purging type. Tania’s condition is a clear case of the restricted type of anorexia since she reports no history of self-induced vomiting or abuse of laxatives. From the foregoing discussions, it is evident that psychiatric disorders greatly impact on the patient’s physical health. The case at hand presents some physical health deterioration symptoms arising from the patient’s mental condition. Johnson et al. (2002) points out that medical complications arising from semi-starvation can impair virtually all body systems. The common life-threatening symptoms of anorexia nervosa related to our case are orthostatic hypotension and bradycardia. Orthostatic hypotension is the abnormal reduction in blood pressure when one stands up. This condition may lead to fainting. Tania suffers from this ailment since she complains of occasional fainting. Coupled with this, is the doctor’s suspicion that the patient could be suffering from bradycardia. Sufferers of bradycardia experience slowness of heartbeat below 60 beats per minute. The general practitioner for the patient in our case has recommended an electrocardiogram (ECG) examination and a referral to a cardiologist. These are indicative of cardiovascular complications. Another telltale effect of anorexia nervosa is that patients tend to be having shorter statures than expected (Vestergaard et al., 2002) . This comes about as a result of bone malformation and growth hormone malfunction as consequences of semi-starvation. The present case has gained only 4cm within a year – which is lower than the expected annual height gain for her age. Other physical health issues brought about by this disorder are persistent gastrointestinal disturbances. The gastrointestinal complications associated with anorexia nervosa include postprandial discomfort, obstipation, constipation, delayed gastric emptying and bloating. Mental illnesses such as anorexia nervosa affect all spheres of physical health. From the present case it has been demonstrated that endocrine system is affected by appetite dysregulation and stagnating growth and development. The skeletal system is affected by bone complications. The gastrointestinal organ system is also affected. The most worrying effects on physical health are the cardiovascular complications which may even lead to cardiac arrest. Clinical management of any eating disorder starts with obtaining a patient’s detailed diet and social history. This is because lifestyle issues like nutrition as well as physical activity would form the basis of accurate pathogenesis and treatment regimes. Secondly, the impact of dietary and physical activity on the patient’s current state and future growth and development should be assessed. Thirdly, the severity of the patient’s state and comorbidity issues needs to be clearly defined. Upon the correct prognosis, the patient can be recommended for an in-patient or an out-patient treatment regime. The essential components for outpatient intervention include nutrition therapy, medical treatment and monitoring, and individual cum family therapy. The patient in this case should be hospitalized following her scores on the DSM-IV and the fact that she could be developing life-threatening cardiovascular complications. The American Psychiatric Association (APA, 2000b) outlines 6 primary treatment goals for anorexia nervosa patients: correcting medical complications, Restoring body weight and body composition, Restoring normal growth and development, Normalizing eating patterns, Normalizing menstrual/testosterone levels, and Treating underlying psychosocial and comorbid conditions . The suggested treatment course involves nutrition therapy and weight management (APA, 2000b). Correction of malnutrition in the patient can reverse a number of medical complications caused by anorexia nervosa. Nutrition therapy also improves cognitive functioning which will in turn accelerate participating and benefiting from psychotherapy. Using selective serotonin reuptake inhibitors (SSRIs) is more effective if the nutritional status have been improved since protein deficiency is counterproductive during such treatments. The energy needs of the body should also be met. The re-feeding program should be individualized with the caloric intake gradually increased from 30-40 kcal/kg/day to 70-100kcal/kg/day. The meal plan can borrow from the APA (2000b) Food Guide Pyramid which includes approximately 15-25% protein, 25-30% fat and 55% carbohydrate. Highly fortified cereals or multivitamin supplements are also recommended. Once the target weight has been achieved, a daily intake of 40-60 kcal/kg is recommended for weight maintenance and sustenance of growth and development. For an effective weight management for this case, a weight range consistent with between 15th and 75th percentile on the BMI is appropriate. In consideration of the patient’s age, height and current weight, a weekly weight gain of between 1- 2 pounds per week is recommended (Dulloo, 1997). It is also recommended that strenuous physical exercises be replaced with light strength exercising. This would facilitate muscle tissue replacement. The management of anorexia nervosa requires close collaboration of a clinical care giver like a nurse and a dietician. They work together in the prescription of an individualized meal plan, education of the patient and her family and developing a balanced meal for implementation. Effective communication and follow-up strategies are important for prevention of relapse or adverse outcomes. The dominant attitude among family and medical care givers is that eating disorder patients are individually responsible for conditions and must take the blame (Crisafulli et al., 2010). Such an attitude has detrimental consequences on treatment seeking, recovery and social support for the patient. Although the manifestations of these disorders appear as if they are of personal choice, it is important for all the significant others and medical care providers to appreciate their psychiatric nature. Eating disorder symptoms result from primarily from factors beyond the control of the patients (Vitousek, 1998). It has been demonstrated that nurses who nurture blaming or stigmatizing attitudes towards anorexia patients are less likely to carry out follow-up appointments (Crusifulli, et al., 2008). Negative attitudes and stigma are likely to impede the quality and availability of services to patients with eating disorders (Thompson-Brenner, 2012). Most anorexia patients also contribute to ineffective treatment due to their attitude and personality. It has been hypothesized that eating disorders co-occur with other personality related disorders (Thompson-Brenner, 2012). Anorexia patients are commonly identified with cluster C personality. They have been associated with high levels of frustration and anger. They also manifest low self-esteem and a feeling of incompetence. This could explain Tania’s unfriendly reactions to her family’s concern about her condition and her feeling that her younger brother is popular and outgoing (unlike herself). It is likely that these patients’ personality is worsened by the stigmatizing attitude from the people around them. This case study has a number of implications for the nurses and other medical staff. The most important consideration is to initiate and build a relationship of empathy and trust with the patient. This has been found to be the most effective way of successful positive health promotion (Crusifulli, et al., 2008). Obstructive and impeding attitudes on the part of the medical staff should be eliminated from the practice. Secondly, an outreach program for the family and community care-givers should be geared towards developing working relationships and opening communication channels. At the level of the patient’s level, strategies that positively transform the patients’ feelings should be given priority. They need to learn how to move from sadness to happiness; low to high esteem; self-apathy to interest; and pessimism to optimism (Serpell & Treasure, 2002). Conclusion It has emerged that the efficacy of treatment interventions for eating disorder patients depends on a number of factors. Correct diagnosis of the disorder is very crucial for any meaningful treatment. A well thought out treatment protocol should then be planned and implemented. Three considerations are, however, imperative: attention to both psychiatric and physical symptoms, follow-up, and the role of attitude of the medical professionals and the patients. Nurses charged with providing care services to patients such as Tania should, therefore, take a multi-pronged approach to achieve desirable treatment and curative outcomes. References Ajzen, I. (1991). The theory of planned behavior. Organizational Behavior and Human Decision Processes, 50, 179-211. American Dietetic Association. (2001). Position of the American Dietetic Association: Nutrition intervention in the treatment of anorexia nervosa, bulimia nervosa, and eating disorders not otherwise specified (EDNOS). Journal of American Diet Association, 101(7), 810-819. American Psychiatry Association. (2000a) Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition, Text Revision. Washington, D.C. American Psychiatric Publishing Inc. American Psychiatric Association. (2000b). Practice guidelines for the treatment of patients with eating disorders (revision). American Journal of Psychiatry,(suppl)(157):1-39. Crisafulli, M.D., Thompson-Brenner, H, & Franko, D.(2010). Stigmatization of anorexia nervosa: Characteristics and response to intervention. Journal of Social and Clinical Psychology 7:756–770. Crisafulli, M.A., Von Holle, A. & Bulik, C.M. (2008). Attitudes towards anorexia nervosa: the impact of framing on blame and stigma. International Journal of Eating Disorders, 41,333–339. Dulloo, A.G. (1997). Human pattern of food intake and fuel-partitioning during weight recovery after starvation: a theory of autoregulation of body composition. Proc Nutr Soc, 56,1A,25-40. Garner, D. M., Olmsted, M. P., Bohr, Y., & Garfinkel, P.E. (1982). The Eating Attitudes Test: Psychometric features and clinical correlates. Psychological Medicine, 12, 871-878. Grabarek, C. & Cooper, S. (2008). Graduate Students’ Social and Emotional Functioning Relative to Characteristics of Eating Disorders. The Journal of General Psychology, 135(4), 425–451. Johnson, J.G., et al. (2002). Eating Disorders during Adolescence and the Risk for Physical and Mental Disorders during Early Adulthood. Arch Gen Psychiatry, 59, 545-552. Joiner, Jr., T. E., & Heatherton, T. F. (1998). First- and second-order factor structure of five subscales of the eating disorders inventory. Wiley Interscience, 23, 189-198. Kaye, W.H, Barbarich, N.C., Putnam, K., Gendall, K.A., Fernstrom. J., Fernstrom, M., et al.(2003). Anxiolytic effects of acute tryptophan depletion in anorexia nervosa. International Journal of Eating Disorders, 33(3), 257-267. Lee, S., Lee, A. M., Leung, T, & Yu, H. (1997). Psychometric properties of the eating disorders inventory (EDI-1) in a nonclinical Chinese population in Hong Kong. International Journal of Eating Disorders, 21, 187-194. Morgan, J. F., Reid, F., & Lacey, H. J. (1999). The SCOFF questionnaire: Assessment of a new screening tool for eating disorders. Wiley Interscience, 319, 1467-1468. Pickett, Ginsburg, Mendez, Lim, Blankenship, Foster, Lewis, Ramon, Saltis, & Sheffield 353 Sjostedt, J.P., Schumaker, J.F. & Nathawat, S.S.(1998). Eating disorders among Indian and Australian university students The Journal of Social Psychology, 138, 351-357. Serpell, L., & Treasure, J. (2002). Bulimia Nervosa: Friend or foe? The pros and cons of bulimia nervosa. International Journal of Eating Disorders, 32, 2, 164-170. Stephens, N, M., Schumaker, J.F. & Sibiya, T.E. (1999) Eating Disorders and dieting Behavior among Australian and Swazi University Students. The Journal of Social Psychology, 139, 2;153-158. Thompson-Brenner, H., Satir, D.A., Franko, D.L. & Herzog, D.B. (2012). Clinician Reactions toPatients with Eating Disorders: A Review of the Literature. Psychiatric Services, 63, 1, 73-78. Vestergaard P et al. 2002. Fractures in Patients with Anorexia Nervosa, Bulimia Nervosa, and Other Eating Disorders – A nationwide register study. International Journal of Eating Disorders, 32, 301-308. Vitousek, K., Watson, S., Wilson G.T.(1998). Enhancing motivation for change in treatment-resistant eating disorders. Clinical Psychology Review 18:391–420. Read More